a goal for a client with impaired mobility is to prevent skin breakdown what nursing intervention would best help the client meet this goal

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?

A. Assist the client to orthopneic position
B. Offer the client a bedpan for toileting
C. Offer a protein-rich diet
D. Turn the client every 2 hours

Correct answer: D

Rationale:

2. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

A. Creamy pus
B. Serous
C. Serosanguineous
D. Purulent exudate

Correct answer: C

Rationale:

3. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.